Transitional Care Codes; Group Patient Meetings; Copay Questions

Transitional Care Management Codes

Q: I have a question about the transitional care management (TCM) codes. Medicare never gave any guidance on how to report what day in the seven-day window or 14-day window we see a patient. Does Medicare not care what date we see the patient as long as it is in the window? What happens if the doctor accidently bills for the actual visit before the TCM billing date of exactly 30 days after the discharge? I can see getting into billing trouble just because Medicare has not given sufficient guidance. Am I wrong?

A: You are correct in that Medicare does not require the dates of the "included" visit to be reported. If a doctor accidently bills for the actual visit before the TCM is billed 30-days post discharge, he should either live with the error, or refund the first paid claim and then re-file the correct one.

I'm quite certain it was not Medicare's intent to entrap or make it unduly difficult for providers to report transitional care management. Although I'd be the first to agree that it has caused confusion and was not well explained to either providers or payers.

Switching To a Lower Set of Codes

Q: One of my coders says that if a new patient visit does not meet the new patient visit requirements you can bill the visit as established. I have not been able to find that guidance anywhere. Is my coder correct?

A: Over the years, various Medicare administrative contractors and carriers have opined on this. The general thinking is that if you can't meet the requirements for the codes in a higher sub-category in an E&M category, but you can meet the requirements for the lower sub-category, you can use the lower set of codes.
This issue usually comes up with admits versus subsequent hospital care, but the same rules should apply with new versus established visits. Just because you don't qualify for the new visit doesn't mean there wasn't a visit.

Often providers will bill a new patient as a 99211 if the provider doesn't interface with the patient. Once you've billed the established patient visit, however, most payers won't want to see, or pay for, a new visit type later.

Group Patient Meetings

Q: How to do I bill as the primary-care physician for group patient meetings addressing prevention by lifestyle modification that I lead? Can I use 99412 code: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes? Does this code work for Medicare, Medicaid, and private payers? Also, what documentation is needed and is there a limit on the number of patients that can be included in the meeting?

A: Yes, that's your code. Medicare covers it although there may be some exclusions based on ICD-9 codes. Medicaid and commercial payers may vary in coverage. The documentation should include the content of the session and the length of time. I am aware of no group patient meeting size limitation.

Copay Questions

Q: Can I take a copay as per a patient's plan? Can I charge $10 on top of a copay? Can I charge a flat fee of $20 for each patient instead of a copay? 

A: Yes you can collect a copay. You cannot charge $10 on top of a copay. Copays are a defined percentage of the fee or fixed-dollar amount - that's what you get.

As for flat fees, you can't charge a flat fee if you are a participating provider or an in-network provider that has a relationship with a patient's plan or insurer. I would advise you to read your current payer contracts to get a better sense of their expectations in these areas.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the October 2013 issue of Physicians Practice.